P1816 Cerebral microembolism in low-risk patients with paroxysmal atrial fibrillation before and after pulmonary vein isolationCerebral microembolism in low-risk patients with paroxysmal atrial fibrillation

BACKGROUND

Invasive treatment of atrial fibrillation (AF) becomes more suitable and effective therapy. There are no consistent data describing the occurrence of potential neurological complications in low-risk patients with paroxysmal AF.

AIM

to determine the occurrence, consequences and risk factors for brain white matter hiperintensities (WMH) assessed in magnetic resonance imaging (MRI) in low-risk patients before and after pulmonary vein isolation (PVI) treatment.

METHODS

Eighty patients with symptomatic paroxysmal AF (median age: 58 years (IQR 50-63), K/M: 30/50), CHA2DS2-Vasc ≤ 3 (CHA2DS2-Vasc: 2 (IQR 1-2.5)) were included in the study. Before and after a minimum of 6-month period after PVI-RF treatment (med. 9,9 months, IQR 7.6-11.8 months) a clinical evaluation with brain MRI and Mini Mental State Examination (MMSE) test were determined. Severity of brain WMH in MRI was assessed in the Fazekas scale (pic 1). The efficacy of PVI-RF treatment analyzed in a 7-day Holter monitoring was confirmed in 43 (53.8%) patients.

RESULTS

Baseline WMH lesions were found in 55 (68.8%) patients. Patients with baseline WMH lesion obtained similar results in the MMSE test, compared to patients with a normal brain image in the MRI study. There was a statistically significant more frequent occurrence of cerebral WMH lesions among older patients, with a higher CHA2DS2-Vasc score, with left atrial (LA) dilatation and dysfunction. Factors affecting the severity of the WMH were: the co-occurrence of the patent foramen ovale (PFO) and coronary artery disease (CAD).

After PVI-RF treatment there were no significant changes in the presence and severity of WMH lesions. Similarly, there were no significant changes in the cognitive abilities assessed with MMSE test compared to the pre-procedural evaluation. There were also similar factors predisposing to brain WMH changes: older age, higher CHA2DS2-Vasc score and higher BMI. In turn, the degree of the brain WMH severity after observation period was dependent on age, higher CHA2DS2-Vasc score, presence of PFO and CAD and the initial LA function.

CONCLUSIONS Cerebral microembolism assessed in MRI is often found in low-risk patients with paroxysmal AF, and its presence and severity are associated with LA dilatation and dysfunction, age and higher CHA2DS2-Vasc score. Additional factors affecting the severity of WMH lesions are: the co-occurrence of PFO and CAD. PVI-RF procedure and its efficacy does not influence on MRI lesions. In the population of relatively young AF patients with no significant cardiovascular disease burden, cerebral microembolism is not related to cognitive impairment.

Abstract P1816 Figure. pic 1

P6211Efficacy of comprehensive Managed Care after Acute Myocardial Infarction (MC-AMI) in a long-term follow-up - preliminary experience of a single high-volume center

Introduction

Despite substantial progress in the medical and interventional treatment of acute myocardial infarction (AMI), a long-term prognosis in MI survivors remains unsatisfactory. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawal) is the first program of a comprehensive, supervised care for patients with AMI to improve long-term prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), outpatient follow-up, and prevention of SCD.

Purpose

To assess the effect of MC-AMI on major adverse cardiovascular and cerebrovascular events (MACCE) in 12 months follow-up.

Methods

In this single-center, retrospective observational study we enrolled 1211 patients, out of which 719 consented for participation in MC-AMI and compared them to 1130 subjects in the control group. After propensity score matching two groups of 529 subjects each were compared. Cox regression was performed to assess the effect of MC-AMI on clinical endpoints.

Results

Primarily, MC-AMI has been proved to reduce MACCE rate by 40% in a 12-month observation. Participants of MC-AMI had a higher adherence to cardiac rehabilitation (98 vs. 14%) higher rate of scheduled revascularisation (coronary artery bypass grafting: 9.8% vs. 4.9%, p<0.001; elective percutaneous coronary intervention: 3.0% vs 2.1%, p<0.05) and ICD implantation (2.8% vs. 0.6%, p<0.05) compared to control.

Multivariable Cox regression analysis revealed MC-AMI participation to be inversely associated with the occurrence MACCE at 12 months (HR=0.500, 95%Cl 0.349–0.718, p<0.001). Besides, older age, diabetes mellitus, hyperlipidemia, prior PAD, previous UA, and lower LVEF were significantly associated with the primary endpoint.

12-month FU - freedom from MACCE

Conclusions

MC-AMI is the first program of a comprehensive in-hospital and post-discharge care for AMI patients. MC-AMI improves prognosis by increasing the rate of patients undergoing CR, complete revascularization and ICD implantation, thus reducing MACCE rate by 40% in 12 months. Participation in MC-AMI is inversely related to mortality rate, recurrent MI and heart failure related hospitalization during 12 months.

P6217Managed Care after Acute Myocardial Infarction (MC-AMI) reduces MACE by 45% in 3-month follow-up - results form Poland's National Health Fund program of post-MI care. A single center analysis

Background

Despite progress in the medical and interventional treatment of acute myocardial infarction (AMI) and low in-hospital mortality related to AMI, a post-discharge prognosis in MI survivors is still unacceptable. The Managed Care in Acute Myocardial Infarction (MC-AMI, KOS-zawal) is a program introduced by Poland's National Health Fund aiming at comprehensive care for patients with AMI to improve long-term prognosis. It includes acute intervention, complex revascularization, cardiac rehabilitation (CR), outpatient follow-up, and prevention of SCD.

Aims

To assess the effect of MC-AMI on major adverse cardiovascular events (MACE) in a 3-month follow-up.

Methods

In this single-center, retrospective observational study we enrolled 1211 patients, and compared them to 1130 subjects in the control group. After 1:1 propensity score matching two groups of 529 subjects each were compared. Cox regression was performed to assess the effect of MC-AMI and other variables on MACE.

Results

MC-AMI has been proved to reduce MACE rate by 45% in a 3-month observation. Multivariable Cox regression analysis revealed MC-AMI participation to be inversely associated with the occurrence MACE at 3 months (HR 0.476, 95% CI 0.283–0.799, p<0.005). Besides, older age, male sex (HR 2.0), history of unstable angina (HR 3.15), peripheral artery disease (HR 2.17), peri-MI atrial fibrillation (HR 1.87) and diabetes (HR 1.5), were significantly associated with the primary endpoint.

Comparison of study endpoints between KO Total, n (%) MC-AMI group, n (%) Control Group, n (%) RR 95% CI NNT P n=1058 n=529 n=529 All-cause mortality 19 (1.8%) 7 (1.3%) 12 (2.3%) 0.583 0.232–1.470 105.8 0.247 Hospitalization for HF 31 (2.9%) 12 (2.3%) 19 (3.6%) 0.632 0.310–1.288 75.6 0.202 Myocardial infarction 25 (2.4%) 9 (1.7%) 16 (3.0%) 0.563 0.251–1.262 75.6 0.157 MACE 73 (6.9%) 26 (4.9%)# 47 (8.9%) 0.553 0.348–0.879 25.2 0.012 *Two-tailed Pearson's Chi-square test; MACE, Major Adverse Cardiovascular Events. #Number of patients with at least one MACE; in 2 patients 2 endpoints occurred. This explains why the total number of MACE is lower than the sum of all endpoints.

MC-AMI vs. control - MACE in 3 months up

Conclusions

MC-AMI is the first program of a comprehensive. Participation in MC-AMI – a first comprehensive in-hospital and post-discharge care for AMI patients for AMI patients improves prognosis and reduces MACE rate by 45% as soon as in 3 months.

Correlation of heart rate variability parameters and QT interval in patients after PTCA of infarct related coronary artery as an indicator of improved autonomic regulation

The purpose of this study was to determine if PTCA of the infarct related coronary artery (IRA) in the late phase of myocardial infarction (MI) can improve autonomic regulation of sinus rhythm and electrical stability of the myocardium measured by heart rate variability (HRV), QT, QTc, and its dispersion (QTd) and if any correlation exists among these measures. The study was performed in 25 patients (21 male, age: 50 +/- 9 years, EF: 52% +/- 11%) in the late phase of MI (2.5 +/- 1.5 months). HRV parameters were calculated automatically. QT, QTc, and QTd were measured manually from a 12-lead surface ECG (50 mm/s). All measurements were made before and 3-5 days after PTCA. Day and night parameters of HRV were sampled over two periods: 2 pm to 10 pm (day) and 10 pm to 6 am (night). Parameters of HRV measured from whole recordings were significantly higher after successful PTCA: SDRR (116 +/- 31 vs 128 +/- 38 ms), SD (55 +/- 17 vs 62 +/- 22 ms), rMSSD (30 +/- 13 vs 36 +/- 14 ms) and HF (246 +/- 103 vs 417 +/- 224 ms2). Significant differences were found during daytime for SD, rMSSD, and HF, and during nighttime for SDRR, SDANN. QT interval duration, QT corrected to the heart rate, and QT dispersion were significantly lower after PTCA (QTd: 54 +/- 15 vs 39 +/- 12 ms). There was no correlation between HRV and QT values before PTCA. High correlations were found after the procedure, particularly between QTd and nighttime HRV.

CONCLUSIONS

PTCA of IRA in the late phase of MI enhances sympathovagal regulation of the cardiac rhythm and the electrical stability of the heart, which may be prognostically important.

Value of heart rate variability parameters for prediction of serious arrhythmic events in patients with malignant ventricular arrhythmias

Heart rate variability (HRV) assesses the electrical stability of the heart and can identify patients at risk of sudden cardiac death (SCD). The value of 10 HRV parameters from 24 hour ECG (in both time and frequency domain) to predict serious arrhythmic events (SAE) in a group of 56 patients with ventricular tachycardia and/or ventricular fibrillation of different etiologies not due to acute myocardial infarction was explored. Eighteen patients had low left ventricular ejection fractions (LVEF). During follow-up (6-46 months, mean = 24) 8 SCD and 12 recurrences of malignant ventricular arrhythmias or ICD discharges were recorded. Proportional hazard analysis (Cox model) for SAE revealed that the mean of all 5 minute standard deviation of RR intervals (SD) and the amplitude of low frequency spectrum (L) were independent risk factors of SAE (P < 0.05). The best models were: SD+EF and L+EF where predictive values were high (sensitivity approximately 60%, specificity over 95%, positive predictive value over 90% and negative predictive value approximately 80%). Event-free survival curves revealed a significantly shorter survival in patients with EF < 40%: 47% vs. 92%, SD < 43 ms; 56% vs. 92% and L < 16 ms; 56% vs. 89% (all P < 0.001) after 2 years. The subgroup with low EF and SD < 43 ms revealed a significantly shortened survival (27% vs 83% at 2 years, P < 0.01). Some HRV parameters, SD from the time and L from the frequency domain, were predictive of a fatal outcome in VT/VF patients. Combined SD+EF and L+EF values are powerful predictors of serious arrhythmic events.

Dispersion of the QT interval as a predictor of cardiac death in patients with coronary heart disease

Abnormal dispersion of the QT interval (QTd), measured as interlead variability of QT, may reflect a regional variation in duration of ventricular action potential and, hence, of cardiac electrical instability. In this retrospective study, we analyzed the effect of QTd on survival and its relation to other known predictors of subsequent cardiac death (CD) and sudden cardiac death (SCD) in 162 patients with coronary heart disease (CHD). QTd was calculated as the difference between the highest and lowest values measured in each of the 12 ECG leads (Qtmax - QTmin). Seventeen CDs occurred, including nine SCDs, during a 25 +/- 11 month follow-up. There were significant differences in CD (P < 0.001 in log-rank test) and in SCD (P < 0.01). The 1- and 3-year survivals were 87.5% and 76.5% in patients with QTd > 0.060 seconds versus 98% and 93.5% in patients with QTd < 0.060 seconds, respectively. Additionally, a stepwise Cox regression analysis revealed that increased QTd was an independent risk factor of CD and SCD. A cut-off value of 60 ms for QTd had a 53% sensitivity and 79% specificity in discriminating patients who are at risk of CD. The positive and negative prognostic values were 23% and 93%, respectively. Our findings support the hypothesis that increased QTd has a prognostic value in the stratification of patients with CHD independent of other known risk factors.

Heart rate variability: its association with hemodynamic function of the left ventricle in patients with coronary heart disease

Patients with heart failure secondary to coronary heart disease (CHD) are characterized by an imbalance of the autonomic nervous system, which can be assessed by analysis of the heart rate variability (HRV). However it is still unclear whether all patients with CHD reveal suppression of HRV and if it is related to hemodynamic function and contractile disturbances of the left ventricle. To answer these questions data from 105 consecutive patients were analyzed and compared with 17 healthy subjects. All study participants underwent 24-hour ambulatory ECG recordings with calculation of HRV parameters and angiographic examination after collection of clinical data and other noninvasive evaluations. Time- (SDRR, SDANN, SD, pNN50) and frequency- (LF, HF) domain parameters of HRV were assessed. All ventriculographic and hemodynamic measurements were used in the analysis. Highly significant correlations were found between all HRV parameters, and left ventricular ejection fraction (LVEF) and left ventricular end-diastolic pressure (P < 0.001). Patients with LVEF < 40% were characterized by significantly lower values of HRV and impairment or lack (LVEF < 20%) of diurnal variation of frequency-domain measurements of HRV. Patients with segmental akinesis or dyskinesis also had lower values of HRV. The group with dyskinesis was characterized by significantly lower diurnal rhythms of LF and HF, independent of LVEF.